1194891424 NPI number — JEFFREY M STARK, DPM

Table of content: (NPI 1194891424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194891424 NPI number — JEFFREY M STARK, DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY M STARK, DPM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194891424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 DUNCAN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11572-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-765-3500
Provider Business Mailing Address Fax Number:
516-536-4236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 DUNCAN PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11572-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-765-3500
Provider Business Practice Location Address Fax Number:
516-536-4236
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STARK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
516-764-3500

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  N003165-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00490042 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com